Aetna Better Health® of Florida
261 N University Drive
Plantation, FL 33324
Prior Authorization Form
MMA/FHK/Comprehensive/LTC
Prior Auth MMA/FHK Fax: 1-860-607-8056; Obstetrical (OB) Fax: 1-860-607-8726 Prior Auth Telephone: 1-800-441-5501
Comprehensive/Long Term Care Requests Fax: 1-844-404-5455 Comprehensive/Long Term Care Telephone: 1-844-645-7371
A determination will be communicated to the requesting provider
• Visit ProPat Search Tool to research whether a service requires prior authorization:http://www.aetnamedicaidportal.com/propat/Default.aspx
• An authorization is not a guarantee of payment. Member must be eligible at the time services are rendered. Services rendered must be a covered health
plan benefit and medically necessary with prior authorization as per plan policy and procedures.
• All Inpatient and Observation Hospital admissions for MMA/FHK/Comprehensive members must be called in to the MMA/FHK Prior Authorization
Department: Phone number 1-800-441-5501
TYPE OF REQUEST
*URGENT/EXPEDITED (to be used when non-urgent/standard prior authorization could seriously
jeopardize the life o
r health of a member, the member’s ability to attain, maintain, or regain
maximum function, or a delay in treatment would subject the member to severe pain that could not
be adequately managed without the service requested—response within 2 calendar days for Medicaid
and Comprehensive/LTC members; 3 calendar days for Florida Healthy Kids)
*NON-URGENT/STANDARD (for routine services – response within 7 calendar days for Medicaid
and Comprehensive/LTC members; 14 calendar days for Florida Healthy Kids)
OUTPATIENT
HOME HEALTH CARE
DME/Supplies
PATIENT INFORMATION
Asterisk (*) Indicates REQUIRED fields. Incomplete requests will delay the authorization process.
Please include pertinent clinical notes to expedite this request.
* Membership Type: MMA FHK Comprehensive LTC
Patient Name: Last First
MI
*Member ID/Medicaid ID:
*Date of
Birth:
*PCP Name: *Phone:
( )
*Fax:
( )
*PCP Contact Name:
REQUESTING PROVIDER INFORMATION
*Requesting Provider Name: *Requesting NPI: *Requesting TIN:
*Requesting Contact Name: *Phone:
*Fax:
SERVICING PROVIDER INFORMATION
Servicing Provider same as Requesting Provider (Please select if the Provider’s information above is the same)
*Servicing Provider Name:
*FL Medicaid Provider#: *Servicing NPI: *Servicing TIN:
*Servicing Provider Contact Name:
*Phone:
(
*Fax:
*Servicing Facility Name: *FL Medicaid Provider#: *Facility NPI:
*Facility TIN:
*Servicing Facility Contact Name:
*Phone:
*Fax:
AUTHORIZATION REQUEST
*Start Date: *End Date:
*Have services already been rendered? Yes No
*Total Units/Visits (Total units should be based on CPT/HCPCS description of units):
*Procedure Codes:
*ICD- 10 Codes:
Comments:
CLINICAL INDICATIONS/RATIONALE FOR REQUEST: *DME, Home Health, Therapies and Infusions must have Rx attached.
To expedite a determination on your request for services, please attach clinical documentation/medical records to support your request. Please
include the following: Conservative treatment tried and failed, applicable diagnostic testing with results and lab values and a medication list.
ATTESTATION: I hereby certify and attest that all information provided as part of this prior authorization request is true and accurate.
*
Provider Signature: _______________________________ *Date: _______________________
aetnabetterhealth.com/florida
FL-19-09-20
click to sign
signature
click to edit
![]()
